医院-社区-患者三元联动延续护理模式在慢性病管理中的效果探讨
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摘要
目的探讨"医院-社区-患者三元联动"延续护理模式在新发糖尿病、新发高血压及心脏支架术后患者出院后的应用与干预效果。方法对2016年7月-2017年3月我院本部下转社康中心的3种慢性病出院患者共158例,实施"医院-社区-患者三元联动"延续护理干预,分别在干预前、干预后1周、4周、3个月、1年进行服药依从性(MMAS-8)、日常生活能力(ADL)、生活质量(SF-36)评分,通过干预前后的变化进行比较。结果干预1年后,患者服药依从性、日常生活能力、生活质量评分较干预前均有大幅度提高,干预前后比较差异有统计学意义(P<0.01)。结论 "医院-社区-患者三元联动"延续护理模式能为出院患者提供出院后不间断护理服务,提高患者服药依从性、日常生活能力,提升生活质量,让患者出院后能顺利回归社区、家庭。
Objective To study the application and intervention effect of transitional care base on the three party linkage of hospital-community-patients in community nursing after discharged from hospital.Methods 158 discharged patients were discharged from the hospital from July 2016 to March 2017 to be implemented based on the three party linkage of hospital-community-patients intervention.The Medication compliance(MMAS-8),daily living ability(ADL),quality of life(SF-36),and quality of life(SF-36)were carried out before and after intervention.The score was compared by changes before and after intervention.Results After one year,the patient's medication compliance,daily living ability and quality of life were greatly improved.There were statistically significant differences before and after intervention(P<0.01).Conclusion The transitional care based on the three party linkage of hospital-community-patient mode can provide uninterrupted nursing service for the discharged patients after discharge,and make the patients return to the community and family smoothly after discharged from the hospital,greatly improve the compliance and daily living ability of the patients,and improve the quality of life.
Objective To study the application and intervention effect of transitional care base on the three party linkage of hospital-community-patients in community nursing after discharged from hospital.Methods 158 discharged patients were discharged from the hospital from July 2016 to March 2017 to be implemented based on the three party linkage of hospital-community-patients intervention.The Medication compliance(MMAS-8),daily living ability(ADL),quality of life(SF-36),and quality of life(SF-36)were carried out before and after intervention.The score was compared by changes before and after intervention.Results After one year,the patient's medication compliance,daily living ability and quality of life were greatly improved.There were statistically significant differences before and after intervention(P<0.01).Conclusion The transitional care based on the three party linkage of hospital-community-patient mode can provide uninterrupted nursing service for the discharged patients after discharge,and make the patients return to the community and family smoothly after discharged from the hospital,greatly improve the compliance and daily living ability of the patients,and improve the quality of life.
引文
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[2]高俊俊,靳艳,张铭利.延续性护理的国内外研究现状及展望[J].当代护士(下旬刊),2016(8):16-18.
[3]刘彩虹.延续性护理对老年高血压患者自我管理行为的影响[J].现代养生,2017(2):156.
[4]杨海苓,王萍,侯文秀,等.医院-社区-家庭三元联动延续护理平台的设计及应用[J].中华护理杂志,2016,51(9):1133-1137.
[5]谢凤兰,成守珍,蔡卫,等.延续护理服务部专职工作岗位的设立及实践[J].中华护理杂志,2013,48(1):47-50.
[6]彭刚艺,刘雪琴.临床护理技术规范(基础篇)[M].2版.广州:广东科技出版社,2013:439-447.
[7]李杨.脑卒中患者延续性护理干预的效果评价[D].长春:吉林大学,2016.
[8]候凯旋,闫素英.慢病患者药物依从性量表的研究[J].中国医院药学杂志,2017(21):192-196.
[9]赵丽蓉,陈琪,李莺.日常生活活动能力量表在分级护理管理中的应用效果[J].护士进修杂志,2016,31(13):1184-1186.
[10]张家仕,冼绍祥.PRO量表及SF-36量表测定高血压患者生活质量效果评价[J].广东医学,2017,38(16):2525-2527.
[11] Cossette S,Frasure-Smith N,Vadeboncoeur A,et al.The impact of an emergency department nursing intervention on continuity of care,self-care capacities and psychological symptoms:Secondary outcomes of a randomized controlled trial[J].International Journal of Nursing Studies,2013,3(3):666-676.
[12] Coleman E A,Smith J D,Frank J C,et al.Preparing patients and caregivers to participate in care delivered across settings:The care transitions intervention[J].Journal of the American Geriatrics Society,2013,11(11):1817-1825.
[13]吉云兰,崔秋霞,单君,等.个体化延续护理对改善高血压患者生存质量的效果[J].护士进修杂志,2012,27(15):1401-1403.